Reverse flow cross leg sural flap as a reconstructive option for traumatic defects in the lower leg circumventing free flaps

Abstract

Very few flaps described in the literature would be as versatile as the reverse sural flap. In spite of its few shortcomings, it is one of the most widely used flaps for lower third defects in the leg because of the paucity of tissues in the region. In a lot of situations, free tissue transfer is the only feasible option because of non-availability of local options in the involved limb. In such a scenario, a reverse sural flap from the contralateral leg can be manoeuvred in a cross leg fashion as an alternative to free flap. It employs skin and soft tissue from the opposite limb which can easily cover large defects in the lateral malleolar and tendoachilles region which would be unachievable with a traditional cross leg flap. A prospective study was developed from September 2018 to March 2020 at SMS Hospital, Jaipur. A total of 10 patients underwent flap cover. Rigid fixation with the help of external fixator was used to prevent flap avulsion, and flaps were divided at 3 weeks. All cases were done in 2 stages, fixed with external fixator and divided at 3 weeks. All 10 flaps survived without any flap failure. One flap had ischaemic changes in the distal most part of the flap which was later debrided and flap advanced to cover the defect. Successful coverage of defect was achieved in all 10 patients, and donor site healed uneventfully. In our experience, a reverse flow cross leg sural flap is a significant option for leg defects where there is a paucity of nearby tissues for stable flap cover and as an alternative to free flap. It is an excellent option for covering large defects over the lateral side of the leg where a traditional cross leg flap cannot reach. It can also circumvent the use of free flaps in patients who cannot undergo a long duration surgery. The relative simplicity of this flap makes it a very useful flap for large defects of the lower third of leg. Level of evidence: Level IV, therapeutic study.